Why Kansas let Adrian and Evan die

Dianne Keech, a former Kansas child welfare official and currently a child safety consultant, was asked by the Wichita Eagle and Fox News to analyze case files regarding the highly-publicized deaths of Adrian Jones and Evan Brewer. I asked Ms. Keech to prepare a guest blog post about the factors contributing to the deaths of Evan and Adrian. She prepared a ten-page document, which you can access here. Below, I highlight some of her conclusions.

Calls to the Kansas child abuse hotline began when Adrian Jones was only a few months old. There were 15 screened-in reports for Adrian before he was six years old. Out of 15 reports in total that KCF investigated, Keech found that there was only one substantiated allegation of abuse, and that was based on an investigation by law enforcement. After Adrian was removed from his mother’s custody due to lack of supervision and placed with his father and stepmother, calls alleged that there were guns all over the house, that the stepmother was high on drugs, that Adrian had numerous physical injuries, that he was being choked by his father and stepmother, and that he was beaten until he bled. Adrian’s father and stepmother consistently denied every allegation and the agency did nothing to verify their stories. Adrian’s body was found in a livestock pen on November 20, 2015. It had been fed to pigs that were bought for this purpose. It was later found that Adrian’s father and stepmother had meticulously documented his abuse through photos and videos. They are serving life terms for his murder.

DCF received six separate reports of abuse of little Evan Brewer between July 2016 (when he was two years old) and May 2017. These reports involved methamphetamine abuse by the mother, domestic violence, and physical abuse of Evan. Only three of these reports were assigned for investigation and none were substantiated. In the last two months of Evan’s life, the agency received two reports of near-fatal abuse, one alleging that he hit his head and became unconscious in the bathtub and the other alleging that his mother’s boyfriend choked Evan and then revived him. The first of these reports received no response for six days and the investigator apparently accepted the mother’s claim that the child was out of state. The investigator of the second report also never laid eyes on Evan. On September 22, a landlord found Evan’s body encased in concrete on his property. Horrific photos and videos documented Evan’s months of torture by his mother and her boyfriend. His mother and her boyfriend have been charged with first-degree murder.

Looking at Root Problems

Keech believes that there are three root problems that led to Adrian and Evan’s deaths: a dangerous ideology, the pernicious influence of a well-heeled foundation, and faulty outcome measures used by the federal government. These are discussed in order below.

Dangerous Ideology: Signs of Safety is a child protection practice framework that was never officially adopted by Kansas. But Keech alleges that its philosophy has permeated all aspects of child welfare practice in the state. The Signs of Safety framework, according to its manual, seeks to avoid “paternalism,” which “occurs whenever the professional adopts the position that they know what is wrong in the lives of client families and they know what the solutions are to those problems.” Signs of safety links paternalism with the concept of subjective truth, citing “the paternalistic impulse to establish the truth of any given situation.” According to Keech, this implication that all truth is subjective means that investigating “facts” is a worthless task. Workers are encouraged to “engage” parents, not investigate them. Keech gives numerous examples of how this practice approach left Evan and Adrian vulnerable to further abuse. When Adrian’s younger sister was brought to the hospital with seizures, she was diagnosed with a subdural head trauma that was non-accidental. But when Adrian’s stepmother insisted that Adrian inflicted the injury with a curtain rod, DCF believed her and did not substantiate the allegation–not even finding her neglectful for letting the child be hurt. When DCF received a report that Evan’s mother was using methamphetamine and blowing marijuana in his face, they accepted her denials and closed the case with no drug test required.

Along with a new practice framework, Kansas adopted a new definition of safety. As in many other states, safety in Kansas has been redefined as the absence of “imminent danger.” This is in contrast to “risk,” which connotes future danger to the child. As a result, children can be paradoxically found to be at high risk of future harm but safe–which happened twice with Adrian. (He was found to be at “moderate” risk three times.) As long as a child is deemed “safe,” the child cannot be removed from home. The decoupling of risk from safety explains why both Adrian and Evan were found to be “safe” 18 times in total, when they were anything but. This is a common situation in many other states. “Risk,” on the other hand, triggers an offer of services, which can be refused, which is what Adrian’s father and stepmother did when he was found to be at risk. I’ve written about the case of Yonatan Aguilar in California, who was found four times to be at high risk of future maltreatment but “safe.” His parents refused services. He spent the last three years of his life locked in a closet until he died.

Pernicious Influence: Casey Family Programs is a financial behemoth with total assets of $2.2 billion. Its mission is to “provide and improve, and ultimately prevent the need for, foster care.'”Over a decade ago, Casey set a goal of reducing foster care by 50% by the year 2020. Casey works in all 50 states, the District of Columbia, two territories and more than a dozen tribal nations. It provides financial and technical assistance to state and local agencies to support its vision. It conducts research, develops publications, provides testimony to promote its views to public officials around the country. As Keech puts it, “There is not a corner of child welfare in the United States where Casey is not a highly influential presence.” Keech has experienced firsthand Casey’s efforts to pressure Kansas to reduce its foster care rolls. At a meeting in that Keech attended in 2015, Casey used “peer pressure” to “shame one region for having a higher foster care placement rate. Casey adopted and promoted the Signs of Safety approach discussed above.

Faulty Federal Outcome Measures: The Child and Family Services Review (CFSR) is an intense federal review of the entire child welfare system. If a state does not pass the review (and no state has passed, to date) then the state must agree with the federal government on a Program Improvement Plan (PIP) or lose funding. Keech feels that the federal reviews can be manipulated by states to improve their outcomes at a cost to child safety. For example, one of the two measures of child safety is timely initiation of investigations. When a hotline screens out a report (as was done three times with Evan) or a case manager fails to report a new allegation (which was done three times while Adrian had an open services case) the agency does not need to worry about timely initiation of an investigation. Another CFSR outcome is “reduce recurrence of child abuse and neglect, ” which is measured by calculating the percentage of children with a substantiated finding of maltreatment who have another substantiated finding within 12 months of the initial finding. This outcome can be improved by failing to investigate reports, or investigating them but failing to substantiate. Only one of the allegations involving Adrian was substantiated; three of the allegations involving Evan were not even investigated and the other three were not substantiated. By not substantiating allegations, Kansas reduces its recurrence rate.

The factors that Keech discusses are not unique to Kansas and are occurring around the country, in states including most of America’s children. All of these states should consider Keech’s recommendations for protecting Kansas’ children from the fate of Adrian and Evan. Most importantly, states need to prioritize the safety of children over and above any other consideration. The primary goal of child welfare must be the protection of children, not reducing entries to foster care. The artificial division between risk and safety should be eliminated and risk should be allowed to inform safety decisions. States must treat substance abuse, domestic violence, criminal activity, mental health issues, and parental history of maltreatment, as real threats to child safety. Workers must be empowered and required to gather all of the information needed to determine the truth of allegations, not rely on adults’ self-serving denials. And they must be allowed–and required–to request out of home placement when there is no other way to protect a child.

7 thoughts on “Why Kansas let Adrian and Evan die”

I managed the second agency in North America to implement the Signs of Safety approach through its first 11 years, and it is not at all what Ms. Keech says it is. The main focus in the Signs of Safety in every family situation is to make sure the children are surrounded by stable and committed adults, in addition to the parents, who know all about the worries, whether they are substantiated or not, and know what to do to make sure the dangerous things that may have happened can’t happen going forward. When a child has a subdural head trauma, we do want to know how it happened, though we also realize that what we think we know might be wrong. We always make a plan with the family and safety network to make sure something like that won’t happen again. In situations like this it often means the child will need to have more than one caretaker within sight and sound of the child at all times, and that one of the caretaker’s must be someone who could not have caused the trauma. If these cases didn’t have this sort of safety network and safety plan, then what was done wasn’t Signs of Safety. More likely what was done was the sort of traditional investigation where the children don’t give enough information, parents provide some sort of story, the agency and attorney’s don’t think they can prove the parents hurt their own child, and so everyone walks away worried, doing nothing that might make the children safer, and often leaving the children in even more danger. It’s this sort of casework as usual that both the Casey Family Programs, the Federal Child and Family Review, and agencies using the Signs of Safety approach seek to change.

Hi Dan, thanks for your comment. Kansas never actually adopted the Signs of Safety model. But it sounds like they used the manual referenced in my blog to support a philosophical turn in the agency to reject concepts of investigation and objective fact in favor of partnerships with parents and taking them at their word. IF they had actually adopted the practice model, perhaps safety would have improved, not declined. It sounds like it was a very positive model in your experience.

You published a critique about something you don’t seem to understand, and you defend what you did by writing “It sounds like they used the manual?” We know from our research that the most clear indicator of likely future harm to a child is someone making a report. Before that’s happened 10 times for the same child, we should no longer even need an investigation to tell us the child is in significant danger. We’re investigating children to death when we could be using our time and resources to protect them instead. At the same time we don’t have the funding or the foster homes to put every child who’s been reported 10 or more times into foster care. Our systems all know way too many children who’ve been reported too many times. We also know from our research about the outcomes of foster care that putting more children in foster care is about the only thing we could do that would be worse for the children and their families than what we’re doing now. I struggled as a supervisor and manager in Minnesota’s child welfare system for years because I could clearly see that what we were doing was making things worse for children, their families, and our social workers. I just didn’t have a vision for doing the work in a way that could make things better until I came across the Signs of Safety.